Fitness to plead. A prospective study of the interrelationships between expert opinion, legal criteria and specific symptomatology

Background. Psychiatrists are asked to give opinions as to fitness to plead , a legal concept. There is a dearth of research into fitness to plead in t he UK, with no prospective studies and no studies involving the comparison of fit and unfit subjects. In particular, there have been no investigations into the meaning of 'unfit to plead' in terms of psychiatric symptomatolog y, or as to the relative importance of each legal fitness criterion in psyc hiatrists' conclusions as to fitness. Method. The study comprised a prospective evaluation of 479 consecutive ref errals to psychiatrists at court. Individual legal fitness criteria were ex amined as predictors of unfitness. Associations of unfitness, and of indivi dual legal fitness criteria, were examined with Brief Psychiatric Rating Sc ale (BPRS) symptom scores. Results. The two most important of the legal criteria in clinical decisions as to unfitness were whether the person could follow the proceedings of th e trial or give adequate instructions to their solicitor. The legal criteri a concerning trial were more predictive of unfitness than those concerning plea. Unfitness was significantly associated with the presence of positive psychotic symptomatology, in particular conceptual disorganization and delu sional thinking, but not with symptoms of anxiety, depression or withdrawal . Conclusion. Unfitness is most significantly associated with symptoms affect ing comprehension and communication. The fitness criteria could be simplifi ed without loss of power. These results, predominantly concerned with menta l illness, may not generalize to the mentally impaired.